Review of medication errors that are new or likely to occur more frequently with electronic medication management systems
Melita Van de Vreede A D , Anne McGrath B and Jan de Clifford CA Eastern Health, Box Hill Hospital Pharmacy, Nelson Road, Box Hill, Vic. 3128, Australia.
B Pharmacy Department, Austin Health, 145 Studley Road, Heidelberg, Vic. 3084, Australia. Email: anne.mcgrath@austin.org.au
C Peninsula Health, Frankston Hospital Pharmacy Department, Hastings Road, Frankston, Vic. 3199, Australia. Email: jdeclifford@phcn.vic.gov.au
D Corresponding author. Email: melita.vreede@gmail.com
Australian Health Review 43(3) 276-283 https://doi.org/10.1071/AH17119
Submitted: 9 May 2017 Accepted: 22 January 2018 Published: 14 May 2018
Journal Compilation © AHHA 2019 Open Access CC BY-NC-ND
Abstract
Objective The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors.
Methods Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents.
Results There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR 2 (moderate) and no ISR 1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were ‘human factors’ and ‘unfamiliarity or training’ (70%) and ‘cross-encounter or hybrid system errors’ (22%).
Conclusions Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues.
What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors.
What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors.
What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.
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